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Children First, Oklahoma’s Nurse-Family PartnershipAnnual Report, SFY 2010shaping the futureDear Reader,
Training sessions for all new Children First nurses begin with this quote by Maya Angelou. It is used to cause a shift in thinking for our nurses. In usual nursing cases, a client presents with a problem. A plan of care is developed and if the plan is followed, the problem is resolved. In this model of home visitation, often the result is not immediate or noticeable in the short-term. We know from the research by Dr. David Olds, that it is usually later or after the intervention has ended when the full benefit of the work is realized.
It is with this frame of reference that I present the 2010 Children First Annual Report. The report highlights our activities and accomplishments for the last year. It shows short-term outcomes attained during the aver­age
length of the intervention and highlights successes that are shaping our clients’ futures. We know that the home visits and services we provide today will make a difference in the health and well-being of our clients and their families for generations to come.
Thanks to all our nurses and supporters who help shape the futures for our families.
Mildred O. Ramsey, R.N., M.P.H.
Director
“When we cast our bread upon the waters, we can presume that some­one
downstream whose face we will never know will benefit from our ac­tion.”
- Maya AngelouTable of Contents
Program Description.......................................1
Client Demographics......................................3
Program Outcomes:
Maternal Health......................................5
Infant & Toddler Health & Development........6
Family Stability.......................................8
Maternal Life Course Development.............8
Family Safety.........................................9
Nurse-Family Partnership Model...............11
Program Activities................................13
Appendices
County Data Chart, SFY 2010..............16
Staffing Distribution Map......................17
NFP Program Report:
Executive Summary..............................18
Children First Logic Model....................21eligible families to care f
or themselves and their babies by providing information and education, assessing health, safety and development and providing linkages to community resources, thereby promoting the well being of families through public health nurse home children firstBACKGROUNDtimelinetimelineProgram created by State Statute, 1996Piloted in 4 counties, Feb. 1997Program function-ing statewide, Oct. 1998Dr. David Olds’ home visitation model selected for implementa-tion, 1996NFP National Service 2003Program Goals:Achieve positive pregnancy outcomesAchieve positive child health and developmentProgram Objectives:Improve parenting skillsImprove pregnancy outcomesStrengthen the parent-child bondImprove parents’ problem solving abilitiesImprove mother’s access to community resourcesImprove child health and developmentHelp clients achieve personal goalsReduce risk factors associated with child abuse and neglect
PROGRAM DESCRIPTION
History
Children First was created in 1996 as a means of improving the health and well-being of children and addressing child maltreatment in Oklahoma. Originally piloted in four counties,1 the Children First program is now delivered through the statewide county health depart­ment
system.
The program utilizes the evidence-based Nurse-Family Partnership (NFP) model of home visitation to address and minimize the risk factors known to contribute to child maltreat­ment.
Based on more than three decades of research by David Olds, Ph.D., the model has been found to reduce the cost of long-term social services and benefit multiple generations by striving to:
Improve pregnancy outcomes by help­•
ing women alter their health-related behaviors, including reducing use of cigarettes, alcohol and illegal drugs;
Improve child health and develop­•
ment by helping parents provide more responsible and competent care for their children; and
Improve families’ economic self-• sufficiency by helping parents develop a vision for their own future, plan future pregnancies, continue their education and find work.2
Services
The Children First program employs registered nurses who make regular home visits to low-in­come
women expecting their first child during pregnancy and continuing through the child’s second birthday. During these visits, nurses:
Assess clients’ health status and socio­•
economic needs;
Assess child health and development;•
Educate and inform mothers about • what to expect in the months ahead;
1 Garfield, Garvin, Muskogee and Tulsa Counties
2 Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership, September 24, 2010.
1children first
SUCCESS
Lindsey McCaslin is a Children First client who knows the challenges of being a
Assistant’s program at Meridian Tech, and will soon begin an internship, all
while raising her daughter Kaitlyn. Lindsey admits it’s been tough juggling
those responsibilities, and says “you have to have it set in your mind or you
won’t succeed.”
A strong support system, including her church and C1 nurse Pam Junkersfeld,
has been key in Lindsey’s success. When she enrolled in Children First, Lindsey
was scared. “I didn’t know what to do, and Pam helped me so much. She’s the
one who got me through everything.”
Now Lindsey is providing a network of support to others in her community by
to other young mothers in situations similar to hers. “They were going through
The group’s motto is “We’re Strong Together,” and Lindsey says the conversation
is one of the most important parts of the group. “It’s just girls getting out their
girls to go out and get pregnant. We’re saying that if you are pregnant, we’re
here for you. You’re not alone.”
Lindsey’s goal is to attend a dental hygienist program. Lindsey and Kaitlyn will
graduate from Children First in April 2011.
Lindsey & Kaitlyn, Logan County
Support and encourage clients to reach personal • goals; and
Connect clients with any community resource • they may need to achieve their goals.
Nurses encourage the inclusion of family and loved ones during visits, as well as work collaboratively with pro­viders.
While nurses perform regular assessments and screenings, program services are not intended to replace the care of a physician/obstetrician.
Enrollment Criteria
Women participating in the Children First program must:
Be expecting their first child;•
Have a household income at or below 185% of the • Federal Poverty Level; and
Be less than 29 weeks pregnant at the time of • enrollment.
Program participation is voluntary. Clients are not obli­gated
to participate for any finite length of time, however mothers benefit from longer involvement in the interven­tion.
2children first
DEMOGRAPHICS
Age:
- 34% of newly enrolled mothers
were under age 19.
- 86% of newly enrolled mothers
were under the age of 25.
25-44yrs, 14.2%
19-24yrs, 51.60%
12-18yrs, 34.20%
Age of C1 Enro llees, SFY 2010
Marital Status:
- 30% of mothers were married at program intake.
- 70% of mothers were married by the time their child
was 2 years of age.
Education:
- 76% of mothers 18 or older at enrollment attained a high school diploma or
GED.
- 13% of mothers who entered the program without a high school diploma or
GED were still working on completing their education at the time of program
graduation.
Income:
- 65% of newly enrolled
families reported an
annual household
income less than
$15,000.
$30,001-$40,000, >$40,000, 1.76%
3.44%
$20,001-
$30,000,
16.27%
$15,001-$20,000,
13.91%
$12,001-
$15,000,
11.95%
$9,001-
$12,000,
14.31%
$6,001-
$9,000,
9.18%
$3,001-$6,000,
7.43%
<$3,000, 21.74%
Annual Household Income, SFY 2010
Race/Ethnicity:
- Children First serves
higher rates of
ethnic/minority groups than represented in the
general Oklahoma
population.
0 20 40 60 80 100
African Amer.
Amer. Ind.
Hisp./Lat.
O White/Non-Hisp. K
C1
Race/Ethnicity served by C1, SFY 2010
Household Composition:
- 47% of C1 mothers live with their husband or partner
- 33% of C1 mothers live with their mother
- 5% of C1 mothers live alone
CLIENT DEMOGRAPHICS
Factors related to instances of child maltreat­ment
and poor birth outcomes have been well documented over the past few decades. These factors include low economic status, young parental age, single parenthood and lack of social support.3 The Children First (C1) program aims to enroll clients who exhibit such char­acteristics
in an effort to improve health and birth outcomes as well as to increase clients’ protective factors and prevent the occurrence of abuse and neglect.
Age
In SFY 2010, clients ranged in age from 12-44 years of age. At intake 34% of clients were 18 years old or younger, 52% were between 19 and 24 years old and 14% were between the ages of 25-44. Clients enrolled in the Children First program are younger first-time mothers when compared to other first-time mothers in Oklahoma, in which less than 9% of all first births occur among women under 18.4
Education
Of the clients 18 or older at enrollment, more than three-fourths (76%) attained a high school diploma or GED. This rate is lower than the Oklahoma population of women 18 years or older with their first birth (86%).5
Income
Of those clients who reported their household income during SFY 2010, 65% of C1 mothers had an annual income less than $15,000 at program intake.
3 A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice. Office on Child Abuse and Neglect (HHS), Washington, DC. Gold­man,
J., Salus, M. K., Wolcott, D., Kennedy, K. Y. 2003. Accessed at http://www.childwelfare.gov/pubs/usermanuals/foundation/foundatione.cfm.
4 OK2SHARE: http://www.health.state.ok.us/ok2share/index2.html. Okla­homa
State Department of Health.
5 Program Evaluation from July 1, 2006 through June 30, 2010. Boeckman, L., Robledo, Candace. University of Oklahoma College of Public Health, Department of Biostatistics and Epidemiology. December 2010.
3Household Composition
Research shows advantages to children living in safe, stable home environments. One factor of family stability is the composition of the household in which the child is currently living. Nearly half (47%) of Children First moth­ers
live with their husband or partner, one-third (33%) live with their mother, and the rest of participants live alone (5%) or in some other type of living arrangement (15%).10
10 Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership. Septem­ber
24, 2010.
Shelby & Madelyn, Oklahoma County
Marital Status
Marital status can be an indication of relationship and family stability, which can impact both the economic and emotional well-being of families. More than 70% of C1 clients were single at the time of enrollment. The percent of clients that were single significantly increased from 73% in SFY 07 to nearly 78% in SFY 09, while the percent married decreased from 23% to 19% during the same time period. This is a significant shift in the population being served. Of all first births in Oklahoma 2006-2008, 50% reported being unmarried.6
Race/Ethnicity
Health disparities are known to exist among racial/ethnic groups including higher rates of infant mortality, teen births, low birth weight births, lower high school graduation rates and insurance coverage.7 Although the overall majority of clients served are Non-Hispanic White, Children First has consistently served higher rates of minority/ethnic groups than represented in the general Oklahoma population. Over the past 5 years, the program’s average client composition consisted of 52% Non-Hispanic White (71% of state population), 13% African Americans (8% of state population), 10% Ameri­can
Indians (8% of state population), and 17% Hispan­ics/
Latinos (8% of state population).8,9
Clients’ County of Residence
More than half (53%) of the families served lived in rural areas outside of the Tulsa and Oklahoma City metropoli­tan
areas. The rest of families served were equally dis­tributed
between the Tulsa metro (23%) and Oklahoma City metro (24%) areas (see Appendix I for a county level breakdown of services).
6 Ibid.
7 2009 Minority Health At A Glance (Oklahoma). Oklahoma State Department of Health, Office of Minority Health. May 2009.
8 Program Evaluation from July 1, 2006 through June 30, 2010. Boeckman, L., Robledo, Candace. University of Oklahoma College of Public Health, Department of Biostatistics and Epidemiology. December 2010.
9 U.S. Census Bureau, State and County QuickFacts. http://quickfacts.census.gov/qfd/states/40000.html. 2009.
Other, 8.7%
American
Indian, 8.8%
African Amer., 12.7%
Hispanic, 19.9%
White, 49.9%
Race/Ethnicity of Newly Enrolled C1 Clients, SFY 2010
OKC Metro, 23.8%
Tulsa Metro, 23.0%
Rural Area, 53.2%
Clients’ County of Residence, SFY 2010
4children first
OUTCOMES
Maternal Health and Life Course Development:
- 12% of C1 mothers who smoked at program intake reported
quitting during their pregnancy.
- 33% of C1 mothers who abused drugs at program intake reported
quitting during their pregnancy.
- 89% of C1 mothers were not pregnant at 12 months postpartum.
- 54% of C1 mothers over age 18 were employed by 24 months
postpartum.
Child Health:
- 89.5% of C1 babies were carried to term (more than 37
Oklahoma.
- 92.7% of C1 babies were born at normal birth weights (more
Oklahoma.
- 85% of C1 babies were fully immunized at 24 months
compared to the state average of 74%.
- 80% of C1 mothers initiated breastfeeding their baby compared to the state rate of 65%.
- 89% of C1 babies never spent time in the NICU compared to the national NFP average of 86% .
Family Stability and Safety:
- 96% of C1 mothers are married to or dating the father
of their child.
- 39% of C1 mothers who reported intimate partner
violence at program intake experienced no physical
abuse during their pregnancy.
- C1 nurses made 496 referrals to mental health
services for mothers participating in the program.
- While C1 babies are at higher risk for abuse and
-
mations of maltreatment are found.
- If the general population of Oklahoma 0-2 year olds
victims of maltreatment.
OUTCOMES
The Children First program benefits new moth­ers
by imparting knowledge on topics such as maternal health and life course development, child health and development, and family sta­bility
and safety. Such information is known to have an impact on the health outcomes associ­ated
with healthy pregnancies and children. Additionally, by helping parents to create safe, nurturing environments, C1 works to prevent children from experiencing childhood traumas that may lead to the adoption of risky behav­iors
in adulthood.
Maternal Health
Infections: STD/UTI
Maternal infections during pregnancy can re­sult
in serious consequences including ectopic pregnancy, stillbirth, preterm delivery, birth defects, newborn illness and even death.11 C1 nurses work to prevent such infections from occurring by educating clients about the risks, recognizing signs and symptoms, monitoring maternal health issues and making appropriate referrals.
Since 2006, 41% of C1 mothers had one or more urinary tract infections (UTI) during the course of their pregnancy (34% for national NFP) and 11% had one or more sexually trans­mitted
infection (STI) (13% for national NFP).12 In general, Oklahoma ranked among the top 20 in the nation for Chlamydia (17th) and Gonor­rhea
(14th) infection and 27th in the nation for Syphilis infections.13
Alcohol/Substance Abuse and Smoking Cessa­tion
Poor habits during pregnancy, such as smoking, alcohol use and substance abuse, have far-reaching implications for the health of infants.
11 March of Dimes Peristats. http://www.marchofdimes.com/peristats/tlanding.aspx?dv=lt®=40&top=10&lev=0&slev=4.
12 Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership. September 24, 2010.
13 Oklahoma State Department of Health, HIV/STD Service. http://www.ok.gov/health/documents/HIV-STD%202007%20County.pdf.
5Zaryiah, Oklahoma County
Use of these substances has been linked to adverse birth outcomes including birth defects, developmental disabilities, preterm births, low birth weight and infant mortality.14
C1 collects data on clients’ smoking habits at program intake and again at 36 weeks of pregnancy. Between SFY 2007-2010, C1 has seen a decline in the number of women who report smoking at program intake, as well as an increase in the number of women who reduce their smoking by 36 weeks gestation. During SFY 2010, C1 experienced a 34% reduction in the percentage of mothers who smoked from intake to 36 weeks (14% reduction in SFY 2007). Furthermore, mothers who continued smoking during this period decreased the amount smoked by 3.2 cigarettes per day at 36 weeks of pregnancy (NFP goal 3.5 cigarettes per day).15 For all first births in Oklahoma during 2006-2008, 13% reported us­ing
tobacco during their pregnancy.
Of those who disclosed alcohol and drug use at program intake, C1 mothers reduced alcohol consumption 29% during pregnancy. C1 mothers also reduced marijuana use (42%), cocaine use (50%) and other drug consump­tion
(37%) during pregnancy.16
Prenatal Care
Early and regular prenatal care leads to healthier preg­nancies
and babies. Women are less likely to deliver prematurely and encounter serious health complica­tions
related to gestational diabetes and pregnancy induced hypertension.17 During the course of a 40-week
14 March of Dimes Peristats. http://www.marchofdimes.com/peristats/tlanding.aspx?reg=40&top=9&lev=0&slev=4.
15 Program Evaluation from July 1, 2006 through June 30, 2010. Boeckman, L., Robledo, Candace. University of Oklahoma College of Public Health, Department of Biostatistics and Epidemiology. December 2010.
16 Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership. September 24, 2010.
17 March of Dimes website: http://www.marchofdimes.com/pnhec/159_513.asp. pregnancy, without additional risks or complications, the American College of Obstetrics and Gynecology recom­mends
14 prenatal visits.
Of the mothers participating in C1, 84% received prenatal care within the first trimester of pregnancy (76% state average) and the remaining women (16%) had visited their health care provider by the completion of their second trimester (18% state average).18 On average, C1 moth­ers
received 12 prenatal visits during the course of their pregnancy.
Infant and Toddler Health and Development
Infant Mortality
Infant mortality, defined as the death of a child less than one year old, is a common factor used to gage the overall health of a population. Currently, Oklahoma ranks 41 in the nation with an infant mortality rate of 8.0 per 1,000 live births.19 The Healthy People 2010 goal for infant mortality is 4.5 per 1,000 live births.
A recent study conducted by the University of Oklahoma, College of Public Health, showed the infant mortality rate among Children First babies between 2001 and 2004 was approximately half that of other Oklahoma first born chil­18
Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership. Septem­ber
24, 2010.
19 Improving Infant Outcomes: Infant Mortality Data. Preparing for a Lifetime Fact Sheet. Oklahoma State Department of Health. June 2010.
0
20
40
60
80
100
No Care 2nd Trimester
Care
1st Trimester
Care
Prenatal Care Received, SFY 2010
84%
76%
16%
18%
0%
6%
6
C1 OK
dren.20 Moreover, C1 clients experienced an infant mortality rate of only 4.35 deaths per 1,000 live births, exceeding The Healthy People 2010 goal.
Breastfeeding
Babies who are breastfed have been shown to be healthier. They have better immune systems, fewer infections and are at lower risk for Sudden Infant Death Syndrome (SIDS).21 All C1 nurses are trained as breast­feeding
educators and provide support to clients early in the postpartum period.
More than three-fourths (80%) of Children First mothers initiated breastfeeding compared to 65% of women in the general Oklahoma population. At 6 months, 22% of C1 mothers report still breastfeeding (27% for Okla­homa
women) and 13% continued to breastfeed at 12 months (12% for Oklahoma women).22,23
Gestational Age
Infants born prematurely (before 37 weeks gestation) or at low birth weights (less than 2,500 grams or 5.5 lbs.) are at greater risk for future health problems including chronic infections, anemia, jaundice, apnea and respira­tory
distress.24 These conditions can be costly and recur­ring.
Developmental delays are also common among this population, which is known to be a risk factor for child maltreatment.
The percentage of infants born preterm to C1 clients was approximately 8% in SFY 2007-2009. During SFY 2010, the percentage of preterm births increased sharply to 11%. This is similar for the state of Oklahoma, where approximately 10% of births among first-time mothers are preterm. 25
20 Carabin, H. et al. Does participation in a nurse visitation programme reduce the frequency of adverse perinatal outcomes in first-time mothers? Pediatric and Perinatal Epidemiology. 2005; 10: 194-205.
21 Oklahoma State Department of Health: http://www.ok.gov/health/Child_and_Fam­ily_
Health/Breastfeeding_Information_and_Support/Why_Breastfeed/index.html
22 Oklahoma Children First Evaluation Report 7. Nurse-Family Partnership. September 24, 2010.
23 Breastfeeding Report Card – United States, 2010. Department of Health and Human Services, Centers for Disease Control and Prevention. August 2010.
24 March of Dimes website: http://www.marchofdimes.com/professionals/14332_1157.asp#head4.
25 Program Evaluation from July 1, 2006 through June 30, 2010. Boeckman, L., Robledo, Candace. University of Oklahoma College of Public Health, Department of Biostatistics and Epidemiology. December 2010.
Birth weight
In the C1 population, the lowest percent of babies born with low birth weights occurred in SFY 2008 (7%), while the first half of SFY 2010 had the highest percent (8%). These results were slightly lower than the percent of births reported being low birth weight in the state. Overall, 7% of infants born to C1 clients had low birth weights compared to 9% among first births in Oklaho­ma.
The Healthy People 2010 objective is to reduce this rate to 5%.26
26 Program Evaluation from July 1, 2006 through June 30, 2010. Boeckman, L., Robledo, Candace. University of Oklahoma College of Public Health, Department of Biostatistics and Epidemiology. December 2010.
C1 Preterm Birth Rates, SFY 2007-2010
vs. Oklahoma Population*
0
3
6
9
12
15
C1 OK
Total Nat.
Amer.
African
Amer.
HispaniW c hite,
Non-Hisp.
*Oklahoma averages are 2008 data (OK2Share: http://www.health.state.ok.us/ok2share/index2.html).
8%
10%
7%
9%
11%
13%
9%
10%
8%
10%
0
3
6
9
12
15
Total Nat.
Amer.
African
Amer.
HispaniW c hite,
Non-Hisp.
*Oklahoma averages are 2008 data (OK2Share: http://www.health.state.ok.us/ok2share/index2.html).
C1 Low Birth Weight Rates, SFY 2007-2010
vs. Oklahoma Population*
7%
8%
6%
7%
12%
15%
7%
8%
7%
8%
7
C1 OK
Dylan, Sequoyah County
Time Spent in the NICU
Infants born preterm or with low birth weights may ex­perience
health complications which make admittance to the Neonatal Intensive Care Unit (NICU) necessary. This hospital stay can be expensive and lengthy depend­ing
on the intensity of needed medical treatment.
Since SFY 2002, 11% of C1 babies were admitted to the NICU (14% for national NFP), spending an average of 5 days (6 days for national NFP).27
Immunizations
As of 2008, Oklahoma ranked 39th in the nation for com­pliance
with the Centers for Disease Control’s recom­mended
vaccination schedule for children under the age of 2 with 74% of children being fully immunized.28
During SFY 2010, 82% of C1 infants were fully immu­nized
at 12 months (85% for national NFP), and by 24 months, 85% had received all recommended immuniza­tions
(91% for national NFP).29 These rates remain slight­ly
higher than the Oklahoma state average of 74%.30
Family Stability
One indicator of family stability is father involvement. Research shows children with involved fathers exhibit math and verbal skills, healthy self-esteem and do well in school.31 According to data collected between SFY 2006-2010, 96% of C1 mothers indicated they are either married to or dating the father of their child.32
Maternal Life Course Development
Subsequent Pregnancy Spacing/Family Planning
Mothers who become pregnant quickly after giving birth have greater risks of complications during the subse­quent
pregnancy, including premature and underweight
27 Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership. September 24, 2010.
28 Tulsa City-County Health Department, Tulsa Area Immunization Coalition website: http://www.tulsaimmunize.org/.
29 Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership. September 24, 2010.
30 America’s Health Rankings. http://www.americashealthrankings.org/Measure/2010/OK/Immunization%20Coverage.aspx.
31 U.S. Department of Health and Human Services. http://fatherhood.hhs.gov/.
32 Program Evaluation from July 1, 2006 through June 30, 2010. Boeckman, L., Robledo, Candace. University of Oklahoma College of Public Health, Department of Biostatistics and Epidemiology. December 2010.infants. Furthermore, pregnancy spacing has an important impact on the mother’s ability to participate in the work­force,
continue or further her education and find adequate child care.
At 6 months postpartum, 3% of C1 mothers were preg­nant
with a second child (4% for national NFP), 11% were pregnant at 12 months (13% for national NFP), 19% were pregnant at 18 months (22% for national NFP) and 32% were pregnant at 24 months (32% for national NFP).33
Workforce Participation
More than half (52%) of mothers over age 18 were work­ing
at the time of program intake. This number is slightly higher than national NFP averages for the first 12 months (46% vs 44% at 6 months and 52% vs 50% at 12 months), and remains fairly consistent throughout the duration of the program (52% at 18 months and 54% at 24 months).34
33 Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership, Septem­ber
24, 2010.
34 Ibid.
0
5
10
15
20
25
30
35
C1 NFP
24 mos 12 mo 18 mos s 6 mos
Subsequent Pregnancy Spacing, SFY 2002-2010
3%
4%
11%
13%
19%
22%
32%
32%
8children first
SUCCESS
Like many women, Laryn Bierig was anxious about becoming a mother for the
raising a child,” explains Laryn, “I had never even changed a diaper before!”
It was because of this apprehension that Laryn decided to enroll in the Children
time of my life,” says Laryn. Luckily her C1 nurse, Judy Catlett, was able to
alleviate her worries by explaining what to expect in the coming months.
“She told me everything she could about pregnancy, what to expect at the
hospital and answered all my many questions,” says Laryn. “I always knew how much he should be eating, sleeping and what was age-appropriate for him.”
In addition to the health and developmental information she received from Judy, Laryn also was encouraged to continue her education. Laryn says she has been so inspired by the program that she decided to change her career path. “I
am currently in nursing school with the hope that after graduating I can one day
make an impact on someone’s life as Judy has ours,” states Laryn.
In part because of Children First, Laryn is now the proud mother of a very
healthy and well-behaved two-year old. “When I get compliments on him, I
know I cannot take all the credit,” explains Laryn, “I would not have been able to do it without Judy.” Laryn and her son Wylie graduated from Children First in
August 2010.
Laryn, Aaron & Wylie, Payne County
Continuing Education
From July 1, 2001 through June 30, 2010, nearly half (44%) of those who entered the program without a high school diploma or GED completed their education by program completion (42% for national NFP) and 13% were continuing their education beyond high school (14% for national NFP); an additional 12% were still working toward their diploma/GED (20% for national NFP).35
Family Safety
The Adverse Childhood Experience (ACE) Study
The ACE Study is a collaborative research project of the CDC and the Department of Preventative Medicine at Kaiser Permanente that has linked the incidence of various ‘risky behaviors’ (i.e. smoking, obesity, alcohol­ism,
substance abuse, sexual promiscuity, etc.) to the occurrence of childhood traumas such as maltreatment, household substance abuse or mental illness, exposure
35 Ibid.to domestic violence, incarcerated household member and parental separation or divorce. Results suggest, in some cases, adults may engage in risky behaviors, like smoking or overeating, as ways to cope with past traumatic childhood events. Furthermore, outcomes indicate a correlation between the number of trau­mas
experienced by an individual and the likelihood of adopting risky behaviors later in life.36 By preventing possible trauma from occurring, C1 hopes to break this cycle of unhealthy lifestyles for children born into the program.
Domestic Violence
The Oklahoma Coalition Against Domestic Violence and Sexual Assault reports as many as 10 million children live in homes where domestic violence occurs, and child abuse and neglect is 15 times more likely in these homes.37 According to ACE study findings, 12.5% of
36 OICA Issue Brief: Childhood Stress: A Ticking Time Bomb. Oklahoma KIDS COUNT Factbook, 2006-2007.
37 Oklahoma Coalition Against Domestic Violence and Sexual Assault website: http://www.ocadvsa.org/.
9adults exhibiting risk behaviors had been exposed to the violent treatment of their mother/stepmother.38
Of the C1 mothers who disclosed domestic violence at the time of program intake, 39% experienced a reduc­tion
in physical abuse between the time of program intake and 36 weeks of pregnancy. Likewise, C1 mothers reported a 58% reduction in fear of a partner or indi­vidual.
39
Substance Abuse
In 2003, as many as 1.5 million children under age 18 lived with at least one parent who had abused an illicit drug during the past year, 10% of which were children under 5 years.40 Substance abuse issues accounted for nearly 16% of confirmed cases of child abuse and neglect in Oklahoma in SFY 2009.41 According to ACE study findings, 4.9% of adults exhibiting risk behaviors had been exposed to a household member using street drugs.42
During the period from program intake to 36 weeks of pregnancy, C1 mothers experienced a 33% reduction in drug usage. At one year of infancy, C1 mothers used drugs 35% less than at program intake.43
Mental Health
According to ACE study findings, 18.8% of adults exhibit­ing
risk behaviors had a household member with mental illness, depression or had attempted suicide.
During SFY 2010, Children First nurses made 496 refer­rals44
for mental health treatment or therapy to women throughout their participation in the program.
38 Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Felitti, V., et. al. American Journal of Medicine, 1998; 14(4).
39 Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership. September 24, 2010.
40 National Household Survey on Drug Abuse. Office of Applied Studies, U.S. Substance Abuse and Mental Health Services Administration, June 2, 2003.
41 Child Abuse and Neglect Statistics, SFY 2009. Oklahoma Department of Human Services.
42 Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Felitti, V., et. al. American Journal of Medicine, 1998; 14(4).
43 Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership, September 24, 2010.
44 Some of these are multiple referrals for the same mother.
Child Abuse and Neglect
According to ACE study findings, more than 11% of adults exhibiting risk behaviors had been abused or neglected as children.
During SFY 2010, Children First nurses made 98 reports of child maltreatment. The majority of these reports were related to neglect (67%), over half (58%) of which involved domestic violence or substance abuse issues. The mother and/or father of the child were named as the perpetrator most often (74%) on reports filed by C1 nurses.
A recent study matched OKDHS data to C1 data in order to determine whether or not child maltreatment was being prevented. Findings from 2002-2006, showed the same proportion of C1 and non-C1 children ages 0-2 years old were named as a potential victim on an Oklahoma Depart­ment
of Human Services (OKDHS) report (11.8% vs. 11.9%), but more reports were made on C1 children than were made on the non-C1 population. This suggests that once C1 children were identified as being at risk for maltreat­ment,
more people were making reports.45
45 Cox, Mary E. An analysis of deaths among infants and children born into Oklahoma’s Children First nurse home visitation program, 1997-2004. Oklahoma State Department of Health, January 2007.
Mental Health Referrals Made by C1 Nurses, SFY 2010
0
1
2
3
4
5
6
6-12 mo 12-18 mos18-24 mos s 0-6 mos Pregnancy
4.6%
5.1%
4.7%
4.5%
4.6%
Emmah, Cleveland County
10The C1 confirmation rate was also the same as or slight��ly
lower than the general population’s rate. This can be interpreted as a positive outcome in that C1 keeps parents with the highest risk factors for abuse from having worse outcomes than the general population of families. If the general population of Oklahoma 0-2 year olds between 2002-2005 had the same confirmation rate as C1 families, 914 fewer Oklahoma children would have been confirmed maltreatment victims.46
46 Ibid.
THE NURSE-FAMILY PARTNERSHIP MODEL
The foundation of the Nurse-Family Partnership (NFP) Model is rooted in the rigorous randomized controlled trials conducted by David Olds, Ph.D., in Elmira, New York, Memphis, Tennessee, and Denver, Colorado. Study outcomes indicate:
Improved prenatal health;•
Fewer childhood injuries;•
Fewer subsequent pregnancies;•
Increased intervals between births;•
Increased maternal employment; and•
Improved school readiness.• 47
In addition to improving such health factors, the NFP model shows significant cost savings for implementing states.
Lasting Benefits
Data from Dr. Olds’ three research trials continue to show positive outcomes, including:
A reduction in child abuse and neglect;•
A reduction in arrests among children;•
A fewer number of convictions of mothers;•
A reduction in ER visits for accidents and poi­•
sonings; and
A reduction in behavioral and intellectual prob­•
lems among children.
47 Nurse-Family Partnership website: http://www.nursefamilypartnership.org.
Sexual Abuse, 4% Emotional
Abuse, 3%
Physical
Abuse, 12%
Neglect, 68%
Mult. Issues,
13%
Abuse by Type Reported by C1 Nurses, SFY 2010
Abuse by Perpetrator Reported by C1 Nurses, SFY 2010
Other
Relative,
G 3% randparent(s), 10%
Mother & Father, 16%
Father/Current Part., 34%
Mother, 30%
Mult. People, 7%
Alexis & Adisyn, Woodward County
11children first
SUCCESS
When Erin went into early labor, she could not have imagined the many ways
her Children First nurse, Lyndse Ashley, would help her family in the coming
months.
“Lyndse was very helpful with everything from questions we had to support we
needed when our daughter, Emily, was born a month premature,” says Erin. After Emily’s birth, Lyndse took the time to ensure the new parents were educated about the needs of a premature infant and how to properly care for
their daughter. “She came a little after I was released from the hospital and had
tons of booklets on how to care for a newborn premie,” explains Erin. As the months progressed, Lyndse continued to work with Erin and her husband to build their parenting skills and track Emily’s growth and develop-
ment. “She made sure Emily was hitting all her milestones, and gave us the skills to help my husband and I continue to be great parents as Emily gets older,” says
Today, Emily is a happy, healthy two year-old and Erin credits Lyndse for helping
her get there. “We really owe part of that to Lyndse and this program,” says Erin. “I never realized what a big part this program played in our lives until Emily graduated from it. We will miss Lyndse, but always know we have the tools and
knowledge to continue on, even when we decide to expand our family.”
Erin and Emily graduated from Children First in November 2010.
Emily, Cleveland County
Fidelity to the NFP Model
The Nurse-Family Partnership has drafted objectives to help implementing agencies track their fidelity to the model and monitor program outcomes related to com­mon
indicators of maternal, child and family function­ing.
The objectives have been drawn from the program’s research trials, early dissemination experiences and current national health statistics (e.g., National Center for Health Statistics, Centers for Disease Control and Prevention; Healthy People 2010). The objectives are intended to provide guidance for quality improvement efforts and are long-term targets for implementing agencies to achieve over time.
Data analyzed by Nurse-Family Partnership for the time frame July 1, 2001 through June 30, 2010, shows that Children First performs well against the national aver­ages
(see Appendix III).
Quality Assurance and Improvement
Central office staff works with C1 teams to ensure fidel­ity
to the NFP model and adherence to Agency standards. Implementing interventions with model fidelity has been shown to positively impact client and program outcomes.
During SFY 10, site visits were provided to administrative areas and contract sites. Results from site visits were uti­lized
to develop specific training topics, develop additional record audit tools and provide technical assistance.
Through collaboration with NFP National Service Office (NSO) all nurses were trained in the use of motivational in­terviewing
(MI) techniques. Activities to assist supervisors and nurses in perfecting MI skills will be carried out in SFY 2011. The NSO has agreed to provide additional education and training as needed to support this effort.
12children first
COST SAVINGS
Pacific Institute for Research and
Evaluation (PIRE):
A 2009 analysis by PIRE found the government had a
54% return on investment for NFP programs that bill
Medicaid for services. This is accomplished by families
and employment skills and returning or entering the
workforce, which decreases client enrollment in social
services, including food stamps and Medicaid.
Adverse Childhood Experiences (ACE)
Study:
In 2009, there were more than 27,970 cases of
maltreatment are vulnerable to permanent brain changes and are at higher risk for illness. Researchers suggest children who adopt risky
behaviors in adulthood as a means for coping
likelihood they will develop one or more of the
leading causes of mortality in Oklahoma,
including heart disease, cancer and diabetes. In
deaths due to heart disease. In hospitalizations alone, the high morbidity of cardiovascular
disease cost residents more than $2.5 billion
annually. Prevention programs like Children First
can impact this cost by stopping child maltreat-
ment from occurring.
Being able to observe and assess parent-child interactions is critical in providing client-cen­tered
parenting education to minimize the risk of child neglect and abuse. To assist our nurses in acquiring these skills, the Nursing-Child Assessment Satellite Training (NCAST) was initi­ated.
All C1 teams are scheduled to receive cer­tification
in NCAST Feeding and Teaching Scales by end of SFY 2011.
Record audits, covering topics such as appro­priate
nursing documentation and Postpartum Depression Screening, were completed by each Lead Nurse. Corrective action plans to address deficiencies were developed and submitted to the C1 central office.
During SFY 2010 new visit guidelines were dis­tributed
by the NSO to all implementing sites. Central office staff provided webinars and indi­vidual
training to assist staff in integrating the new tools into their current practice.
Continued quality improvement efforts for SFY 2011 will focus on aligning current activities with goals and outcomes identified on the C1 Logic Model (see Appendix IV).
PROGRAM ACTIVITIES
The following is a description of Children First services provided during SFY 2010 (July 1, 2009-June 30, 2010). Oklahoma State Statute 63-1-110-1, which established the Children First Fund for the operation of the Children First program, requires the Oklahoma State De­partment
of Health to annually report certain program and family characteristics. The follow­ing
meet this reporting requirement.
13Services Delivered
Nurses (number of non-supervisory, full-time/part-time nurse home visitors)
109
Eligible Referrals (number of women referred to program who met eligibility requirements)
3,566
New Enrollees (number of women who enrolled in the program during SFY 2010)
1,890
Current Participants (number of families that received at least one visit during the last year)
4,073
Completed Visits (number of completed home visits or supervisory visits)
39,464
Births (number of families with completed birth forms)
1,189
Families remaining in program until child’s 2nd birthday
749
Referrals to Children First
Health Dept. Family Planning
2,540
50.2%
WIC
1,215
24.0%
Other
622
12.3%
Self-Referral
219
4.3%
Baby Line
151
3.0%
Indian Health Services
60
1.2%
Health Dept. Maternity Clinic
56
1.1%
Current/Past C1 Client
51
1.0%
Private Physician
36
0.7%
Faith-Based Organization
28
0.6%
Other Pregnancy Testing Clinic
28
0.6%
School
32
0.6%
Department of Human Services (DHS)
23
0.5%
HMO/Health Care Plan
2
0.0%
Total Statewide Referrals
5,063
100.0%
Referrals given to ineligible families
No referrals were made
1,932
93.5%
Start Right Programs (OCAP)
59
2.9%
Oklahoma Parents as Teachers (OPAT)
26
1.3%
Other
22
1.1%
Other Health Department Services (family planning, SoonerStart, Child Guidance, gen­eral
services)
12
0.6%
WIC
10
0.5%
Indian Health Services
2
0.1%
Total
2,067
100.0%
Jennifer & Rayden, Muskogee County
Activities At A Glance, SFY 2010
109 registered nurses made 39,464 • home visits.
4,073 families received services from a • C1 nurse home visitor.
3,566 pregnant women were referred • and eligible to receive C1 services.
1,890 first-time mothers enrolled in • Children First.
1,189 babies were born to C1 partici­•
pants.
749 families stayed in C1 program until • their child reached two years of age.
2,067 referrals were made to families • by C1 nurses.
98 reports of suspected child maltreat­•
ment were made to DHS by C1 nurs­es.
66 counties had C1 services available • to families.
14Program Expenditures, SFY 2010
Administration – Central Office
Salary and fringe
$501,612.35
Travel
$8,803.71
Contractual/Fees
$63,838.50
Supplies/Equipment
$596.97
Data (information technology)
$21,663.57
Other (copiers, motorpool, phones, etc.)
$15,845.51
Total Administrative Costs
$612,360.61
Evaluation
University of Oklahoma
$5,000.00
Nurse-Family Partnership (TA, data)
$13,262.00
Total Evaluation Costs
$18,262.00
Professional Development
Nurse-Family Partnership (training)
$71,412.00
Other training
$5,000.00
Total Professional Development Costs
$76,412.00
Service Delivery
Contracts:
Tulsa-City County Health Department
$1,804,414.00
Oklahoma City-County Health Department
$1,360,181.00
Total Contractual Costs
$3,164,595.00
Community Health Departments:
Salary and fringe
$6,428,728.60
Travel
$453,412.48
Supplies/Equipment
$5,564.52
Fees/Contractual
$47,467.94
Total Community HD Costs
$7,510,025.07
Total Actual Expenditures
$11,381,654.68
Total Expenditure per family served
$2,794.42
15Appendix I: County Data Chart, SFY 2010
County
Com­pleted
Visits
Fami­lies
Served
Eligible Refer­rals
Enroll­ees
Births
Grad­uates
Enroll­ment
Rate
Adair
-
-
0
-
-
-
-
Alfalfa
7
1
1
0
-
-
0%
Atoka
159
16
25
5
1
2
20%
Beaver
2
2
3
0
-
1
0%
Beckham
200
31
42
14
5
6
33%
Blaine
308
29
31
11
6
6
35%
Bryan
985
133
181
85
30
13
47%
Caddo
291
42
35
19
7
6
54%
Canadian
839
74
80
29
25
6
36%
Carter
554
66
83
33
17
10
40%
Cherokee
758
74
41
34
17
9
83%
Choctaw
382
36
58
29
16
1
50%
Cimarron
-
-
-
-
-
-
-
Cleveland
2298
240
183
73
59
20
40%
Coal
296
22
21
7
8
3
33%
Comanche
492
64
28
14
18
11
50%
Cotton
47
8
4
2
1
3
50%
Craig
313
30
32
11
5
2
34%
Creek
424
49
33
24
15
3
73%
Custer
308
31
29
17
12
2
59%
Delaware
466
27
25
10
16
40%
Dewey
-
-
-
-
-
-
-
Ellis
0
1
1
0
-
-
0%
Garfield
798
121
139
52
33
14
37%
Garvin
269
42
46
21
7
6
46%
Grady
202
23
44
18
10
4
41%
Grant
15
2
2
0
-
-
0%
Greer
75
6
17
3
2
2
18%
Harmon
47
5
0
3
2
-
100%
Harper
36
4
4
2
-
-
50%
Haskell
71
7
15
2
2
3
13%
Hughes
64
14
14
4
1
1
29%
Jackson
553
65
112
34
23
5
31%
Jefferson
76
7
10
1
1
1
10%
Johnston
225
29
27
10
7
6
37%
Kay
288
33
68
20
11
3
29%
Kingfisher
704
63
34
25
22
6
74%
Kiowa
46
6
10
1
-
2
10%
Latimer
157
17
34
9
9
3
26%
County
Com­pleted
Visits
Fami­lies
Served
Eligible Refer­rals
Enroll­ees
Births
Grad­uates
Enroll­ment
Rate
Leflore
1281
108
105
34
32
21
32%
Lincoln
577
64
50
28
21
7
56%
Logan
864
118
165
63
30
15
38%
Love
51
13
12
5
1
-
42%
Major
89
12
15
3
2
4
20%
Marshall
306
33
28
13
9
2
46%
Mayes
-
-
3
-
-
-
0%
McClain
423
33
29
7
11
4
24%
McCurtain
431
47
23
32
5
-
100%
McIntosh
189
22
45
7
6
4
16%
Murray
248
25
24
11
8
5
46%
Muskogee
945
115
51
41
32
11
80%
Noble
193
18
14
3
3
1
21%
Nowata
-
-
-
-
-
-
-
Okfuskee
68
9
19
5
3
-
26%
Oklahoma
5202
604
427
267
152
78
63%
Okmulgee
281
34
70
10
5
5
14%
Osage
-
-
-
-
-
-
-
Ottawa
780
85
43
43
23
18
100%
Pawnee
1
1
-
-
-
-
-
Payne
933
109
130
33
32
11
25%
Pittsburg
762
96
58
34
24
15
59%
Pontotoc
27
5
29
6
-
-
21%
Pottawatomie
863
112
179
61
36
4
34%
Pushmataha
61
6
15
3
2
-
20%
Roger Mills
19
3
1
1
1
-
100%
Rogers
858
105
73
44
26
10
60%
Seminole
280
38
69
20
8
5
29%
Sequoyah
416
73
15
14
14
18
93%
Stephens
222
26
36
26
7
-
72%
Texas
326
36
48
25
19
2
52%
Tillman
57
13
10
3
1
-
30%
Tulsa
9176
833
144
377
249
119
100%
Wagoner
25
10
6
4
-
-
67%
Washington
422
57
86
25
16
4
29%
Washita
-
-
1
0
-
-
0%
Woods
52
11
5
9
1
1
100%
Woodward
268
27
26
10
12
2
38%
16Appendix II: Children First Staffing Map
17
Number of Nurses in County**number does not includes Lead Nurse supervisorsTotal number of home visitors: 109TEXASCIMARRONBEAVERHARPERWOODSWOODWARDELLISWASHINGTONGRADYLINCOLNMCCLAINALFALFAGRANTGARFIELDMAJORDEWEYCUSTERWASHITABECKHAMROER MILLSBLAINECADDOCANADIANLOGANPAYNECREEKOKMULGEEHUGHESPONTOTOCGARVINSTEPHENSCOMANCHEKIOWAJACKSONTILLMANCOTTONJEFFERSONLOVECARTERREERHARMONMARSHALLBRYANATOKACOALPITTSBURGLATIMERPUSHMATAHACHOCTAWMCCURTAINLEFLORESEQUOYAHMUSKOGEECHEROKEEADAIRDELAWAREOTTAWAMAYSROGERSNOWATAWAGONERTULSAHASKELLOSAGEKAYNOBLEOKLAHOMAMURRAYJOHNSTONCRAIGSEMINOLELead Nurse SupervisorTotal number of supervisors: 22Unorganized CountiesMCINTOSH222113221711131211231121131422111211811111111
*C1 services available in 66 countiesEXECUTIVE SUMMARY This is the seventh Oklahoma Children First Program evaluation report for the Nurse-Family Partnership (NFP), based on the intervention model developed and tested by Dr. David Olds and colleagues (see Appendix A). The Oklahoma State Department of Health coordinates the implementation of this program in the State of Oklahoma. This report presents analysis of data available from July 1, 2001 through June 30, 2010, and covers the pregnancy, infancy, and toddler phases of the program. Throughout the report, indicators of program implementation, maternal and child health and functioning for Oklahoma Children First Program clients are compared to the national sample of Nurse-Family Partnership clients. OKLAHOMA CHILDREN FIRST PROGRAM PERFORMANCE AGAINST NFP NATIONAL AVERAGES Oklahoma Children First Program performs well against the national averages in the following areas of program implementation and program outcomes, including: • Clients entering the program by 16 weeks of pregnancy; • Clients who initiate breastfeeding; and • Lower number of subsequent pregnancies at 12 and 18 months postpartum. Oklahoma Children First Program has achieved statistically significant reductions in: • Smoking during pregnancy; • Marijuana use during pregnancy; • Alcohol use during pregnancy; and • Experience of violence during pregnancy. Oklahoma Children First Program is lower than the national NFP averages in the following areas: • Clients receive fewer visits in each program phase; and • Retention of clients during pregnancy and infancy program phases. Details about each of these areas of performance can be found below, and in the body of this report. CLIENT CHARACTERISTICS • 23137 women ever enrolled between July 1, 2001 and June 30, 2010: median age 20; 58% completed high school/GED; median education 10 years for non-high school graduates; 75% unmarried; 59% unemployed; 62% Medicaid recipients • Race/Ethnicity: 54% non-Hispanic White; 15% Hispanic; 13% African American/Black; 9% Native American; 7% multiracial/other; 1% Asian PROGRAM IMPLEMENTATION • For Oklahoma Children First Program, 46% of clients entered the program by 16 weeks of pregnancy, a rate higher than the national NFP average of 41%. A total of 92% of Oklahoma Children First Program clients were enrolled by 28 weeks gestation compared to 92% of NFP clients nationwide. • Program guidelines prescribe a certain schedule of visits that a client should receive. Oklahoma Children First Program clients received a lower percentage of those visits as compared to national NFP clients. Percentages of expected visits completed:
Appendix III: Nur
se-Family Partnership Evaluation Report 7 Executive Summary
Appendix III: Nurse-Family Partnership Evaluation Report 7 Executive Summary
18EXECUTIVE SUMMARY o Pregnancy: 66% (73% national NFP) o Infancy: 33% (39% national NFP) o Toddlerhood: 19% (25% national NFP) • Oklahoma Children First Program has closely matched the program guidelines for content of home visits. • Only time spent on maternal role development during infancy (40% vs. 45-50%) and life-course development during Toddlerhood (14% vs. 18-20%) are below NFP program Objectives. • Attrition rates: o Pregnancy: 20.5% (16.1% national NFP) o Infancy: 33.6% (31.8% national NFP) o Toddlerhood: 14.6% (15.2% national NFP) PROGRAM OUTCOMES • A statistically significant reduction of 12% in smoking during pregnancy (16% national NFP average). o A statistically significant reduction of 1.3 cigarettes smoked per day for those who continued to smoke (1.7national NFP average). • A statistically significant reduction of 36% in marijuana use during pregnancy. • A statistically significant reduction of 22% in alcohol use during pregnancy. • A statistically significant reduction of 39% in experience of violence during pregnancy • 9.5% preterm birth rate (9.7% national NFP average); rates for predominant ethnic groups were: 9.3% for Non-Hispanic Whites (9.3% for the national NFP); 8.5% for Hispanics (8.5% for the national NFP); 12.7% for African American/Blacks (11.8% for the national NFP); 9.7% for Native Americans (9.1% for the national NFP). • 9.1% low birth weight rate (9.4% national NFP average); rates for predominant ethnic groups were: 8.3% for Non-Hispanic Whites (8.2% for the national NFP); 7.7% for Hispanic (8.1% for the national NFP); 14.4% for African American/Blacks (13.6% for the national NFP); 8.1% for Native Americans (7.7% for the nation NFP). • The largest proportion of toddlers (28%) scored between the 26th and 50th percentiles for language development; 9% scored below the 10th percentile, compared to 10% of NFP toddlers nationwide. Scoring below the 10th percentile may indicate a delay in language skills. (Note: Prior to 10/1/2006, all toddlers were assessed with the English version of the Language Assessment Form). • At 12 months of infant age, 82% of infants were fully immunized (85% for national NFP). By 24 months of child’s age, 85% were fully immunized (91% for national NFP). Full immunization rates were tracked beginning October 1, 2006. • 80% of clients initiated breastfeeding (national NFP average: 76%); 22% of clients were breastfeeding at 6 months (27% national NFP average); 13% of clients were breastfeeding at 12 months of infancy (16% national NFP average). • At 12 months postpartum, 11% of clients reported a subsequent pregnancy (13% national NFP average). 32% of clients reported subsequent pregnancies within 24 months of the birth of their child (32% national NFP average). • Of those who entered the program without a high school diploma or GED, 44% completed their diploma/GED by program completion (42% for national NFP) and 13% were continuing
19
19their education beyond high school (14% for national NFP); an additional 12% were still working toward their diploma/GED (20% for national NFP). • 54% of Oklahoma Children First Program clients 18 years or older at intake (vs. 56% for the national NFP sample) and 39% of those 17 years or younger (vs. 42% for the national NFP sample) were working at program completion. • Clients were employed an average of 6.3 months during the first postpartum year (6.4 national NFP average), and 6.9 months during the second postpartum year (7.9 national NFP average).
20
Appendix IV: Children First Logic Model
Children First -Logic ModelASSUMPTIONS1. Program services are guided by literature on primary prevention programs and risk & protective factors of child abuse and neglect that show positive results such as:•Prevention programs are most effective when they are tailored to the specific needs of the target population.•The timing of the intervention matters.•Intensity, duration and regularity of the intervention matters.•Programs using modeling, role-playing are nearly twice as effective as programs using non-directive strategies such as counseling and group discussions.•Enhancement of protective factors and minimization of risk factors reduces the occurrence of child abuse and neglect amongst children and families.2. Children First Home Visitation program will utilize the Nurse Family Partnership model to deliver services.•Home visitation programs have been proven to decrease incidence of abuse and neglect of children.INPUTSOUTPUTS-ActivitiesSHORT-TERM OUTCOMES-Objectives•Registered Nurses with valid Oklahoma licenses with training in the NFP model of home visitation services•Transportation for conducting home visits.•Social services / resources.•Partnerships to provide referrals.•Stable C1 funding.•Clinical and administrative support of county health departments•C1 central office staff.•Program Evaluation.•Program monitoring and contract compliance to ensure program fidelity.•NFP Dr. Old’s Model of Home VisitationPOPULATION SERVEDWomen from all 77 Oklahoma counties who are: •At or below 185% of the Federal Poverty Level•Less than 29 weeks gestation•First time mothers•Voluntary Participants-Assess maternal health-Link to health care.-Link to prenatal care.-Educate on consequences of smoking, alcohol and drugs during pregnancy-Identify depression and makereferrals.-Assess child health -Link to health care.-Conduct developmental screenings and make referrals.-Promote breast-feeding.-Educate about nurturing home environments.-Educate about the effects of smoking around the child.•Educate about the effects of domestic violence around the child.-Demonstrate positive parenting techniques-Assist in building skills for problem solving.-Assist in building skills for finding and linking to appropriate community resources.•Link to community services, as needed.•Encourage appropriate stress –coping mechanisms.•Promote and increase father involvement.-Refer to employment or education resources.•Educate on family planning and contraceptive use-Provide positive role model for parent-child interaction.-Provide referrals to public assistance programs when appropriate.-Educate on safe practices and safe home environment such as water, fire, vehicle and wheeled toys safety; poisons, child-proofing home,abusive head trauma and safe sleeping practice.-Educate on domestic violence.-Assess risk of child maltreatment.Perinatal Health•Decreased incidence of STD and UTI among clients during pregnancy•Decreased emergency room usage•Appropriate weight gain•Early recognition and referral for Post Partum DepressionHealth Behaviors•Smoking Cessation•No alcohol usage•No substance usageAppropriate prenatal obstetrical care•Increase in clients receiving 10+ prenatal visitsMaternal HealthTo enhance mother’s health throughout pregnancy and after delivery to ensure adequate care and referrals if necessary.Infant/Toddler Health & DevelopmentTo enhance healthy growth and development.Family StabilityTo enhance family functioning by establishing a trusting, nurturing relationship, improving family support systems and teach problem solving skills.Maternal Life Course DevelopmentTo promote achievement of personal goals in employment, education and personal health.Family SafetyTo promote safe practices and reduce the risk of injury, illness, abuse and neglect.Children First GOALS COLOR GUIDEYellow: Maternal healthPurple: Child Health & DevelopmentBlue: Family StabilityPink: Maternal Life Course DevelopmentGold: Family SafetyInfant Health•Increased breastfeeding initiation and duration•Decreased time spent in NICU, if necessary•Increased gestational age at delivery•Decrease in preterm birthsToddler Health•Immunizations up-to-date•Well Child Checks up-to-date•Decreased emergency room visits due to illness•Appropriate growth patternsPaternal Involvement•Increase paternal involvement during pregnancy, infancy and toddlerhood•Increased communication between mother and father•More Positive Parent-Child InteractionChild and Maternal Living Arrangement•Increased stability of living arrangement for mother and child-Subsequent Pregnancy Spacing and Family Planning•Increased interval between pregnancies, increased use of contraception-Workforce Participation•Increased participation in workforce by clients over 18-Continuing Education•Increased enrollment and attendance of educational or technical program-Appropriate use of Public Assistance programsIncreased use of services available as appropriateDecreased usage of emergency room due to injuriesHome Safety ChecklistSafe Sleep Practices•Increase in safe sleep practices Car Seat Safety•Increased car seat usageDecreased confirmations of abuse or neglect to OKDHSDecreased exposure to home violenceLONG-TERM OUTCOMES-GoalsRev: Nov 09
21This report is submitted in compliance with Oklahoma Statute 63-1-110.1 by:
Terry Cline, Ph.D., Commissioner of Health
Stephen W. Ronck, MPH, Deputy Commissioner, Community and Family Health Services
Annette Wisk Jacobi, JD, Chief, Family Support and Prevention Service
Mildred Ramsey, RN, MPH, Director, Children First
Data:
Miriam McGaugh, Ph.D.
Content and Layout:
Sarah Ashmore, BA
Contact Information:
Oklahoma State Department of Health
Community and Family Health Services
Family Support and Prevention Service
Children First Program
1000 NE 10th Street
Oklahoma City, OK 73117-1299
Web: http://cf.health.ok.gov
Phone: 405-271-7611
Fax: 405-271-1011Oklahoma State Department of Health is an Equal Opportunity Employer. This publication was issued by the Oklahoma State Department of Health as authorized by Terry L. Cline, Ph.D., Commissioner of Health.

Children First, Oklahoma’s Nurse-Family PartnershipAnnual Report, SFY 2010shaping the futureDear Reader,
Training sessions for all new Children First nurses begin with this quote by Maya Angelou. It is used to cause a shift in thinking for our nurses. In usual nursing cases, a client presents with a problem. A plan of care is developed and if the plan is followed, the problem is resolved. In this model of home visitation, often the result is not immediate or noticeable in the short-term. We know from the research by Dr. David Olds, that it is usually later or after the intervention has ended when the full benefit of the work is realized.
It is with this frame of reference that I present the 2010 Children First Annual Report. The report highlights our activities and accomplishments for the last year. It shows short-term outcomes attained during the aver­age
length of the intervention and highlights successes that are shaping our clients’ futures. We know that the home visits and services we provide today will make a difference in the health and well-being of our clients and their families for generations to come.
Thanks to all our nurses and supporters who help shape the futures for our families.
Mildred O. Ramsey, R.N., M.P.H.
Director
“When we cast our bread upon the waters, we can presume that some­one
downstream whose face we will never know will benefit from our ac­tion.”
- Maya AngelouTable of Contents
Program Description.......................................1
Client Demographics......................................3
Program Outcomes:
Maternal Health......................................5
Infant & Toddler Health & Development........6
Family Stability.......................................8
Maternal Life Course Development.............8
Family Safety.........................................9
Nurse-Family Partnership Model...............11
Program Activities................................13
Appendices
County Data Chart, SFY 2010..............16
Staffing Distribution Map......................17
NFP Program Report:
Executive Summary..............................18
Children First Logic Model....................21eligible families to care f
or themselves and their babies by providing information and education, assessing health, safety and development and providing linkages to community resources, thereby promoting the well being of families through public health nurse home children firstBACKGROUNDtimelinetimelineProgram created by State Statute, 1996Piloted in 4 counties, Feb. 1997Program function-ing statewide, Oct. 1998Dr. David Olds’ home visitation model selected for implementa-tion, 1996NFP National Service 2003Program Goals:Achieve positive pregnancy outcomesAchieve positive child health and developmentProgram Objectives:Improve parenting skillsImprove pregnancy outcomesStrengthen the parent-child bondImprove parents’ problem solving abilitiesImprove mother’s access to community resourcesImprove child health and developmentHelp clients achieve personal goalsReduce risk factors associated with child abuse and neglect
PROGRAM DESCRIPTION
History
Children First was created in 1996 as a means of improving the health and well-being of children and addressing child maltreatment in Oklahoma. Originally piloted in four counties,1 the Children First program is now delivered through the statewide county health depart­ment
system.
The program utilizes the evidence-based Nurse-Family Partnership (NFP) model of home visitation to address and minimize the risk factors known to contribute to child maltreat­ment.
Based on more than three decades of research by David Olds, Ph.D., the model has been found to reduce the cost of long-term social services and benefit multiple generations by striving to:
Improve pregnancy outcomes by help­•
ing women alter their health-related behaviors, including reducing use of cigarettes, alcohol and illegal drugs;
Improve child health and develop­•
ment by helping parents provide more responsible and competent care for their children; and
Improve families’ economic self-• sufficiency by helping parents develop a vision for their own future, plan future pregnancies, continue their education and find work.2
Services
The Children First program employs registered nurses who make regular home visits to low-in­come
women expecting their first child during pregnancy and continuing through the child’s second birthday. During these visits, nurses:
Assess clients’ health status and socio­•
economic needs;
Assess child health and development;•
Educate and inform mothers about • what to expect in the months ahead;
1 Garfield, Garvin, Muskogee and Tulsa Counties
2 Oklahoma Children First Program Evaluation Report 7. Nurse-Family Partnership, September 24, 2010.
1children first
SUCCESS
Lindsey McCaslin is a Children First client who knows the challenges of being a
Assistant’s program at Meridian Tech, and will soon begin an internship, all
while raising her daughter Kaitlyn. Lindsey admits it’s been tough juggling
those responsibilities, and says “you have to have it set in your mind or you
won’t succeed.”
A strong support system, including her church and C1 nurse Pam Junkersfeld,
has been key in Lindsey’s success. When she enrolled in Children First, Lindsey
was scared. “I didn’t know what to do, and Pam helped me so much. She’s the
one who got me through everything.”
Now Lindsey is providing a network of support to others in her community by
to other young mothers in situations similar to hers. “They were going through
The group’s motto is “We’re Strong Together,” and Lindsey says the conversation
is one of the most important parts of the group. “It’s just girls getting out their
girls to go out and get pregnant. We’re saying that if you are pregnant, we’re
here for you. You’re not alone.”
Lindsey’s goal is to attend a dental hygienist program. Lindsey and Kaitlyn will
graduate from Children First in April 2011.
Lindsey & Kaitlyn, Logan County
Support and encourage clients to reach personal • goals; and
Connect clients with any community resource • they may need to achieve their goals.
Nurses encourage the inclusion of family and loved ones during visits, as well as work collaboratively with pro­viders.
While nurses perform regular assessments and screenings, program services are not intended to replace the care of a physician/obstetrician.
Enrollment Criteria
Women participating in the Children First program must:
Be expecting their first child;•
Have a household income at or below 185% of the • Federal Poverty Level; and
Be less than 29 weeks pregnant at the time of • enrollment.
Program participation is voluntary. Clients are not obli­gated
to participate for any finite length of time, however mothers benefit from longer involvement in the interven­tion.
2children first
DEMOGRAPHICS
Age:
- 34% of newly enrolled mothers
were under age 19.
- 86% of newly enrolled mothers
were under the age of 25.
25-44yrs, 14.2%
19-24yrs, 51.60%
12-18yrs, 34.20%
Age of C1 Enro llees, SFY 2010
Marital Status:
- 30% of mothers were married at program intake.
- 70% of mothers were married by the time their child
was 2 years of age.
Education:
- 76% of mothers 18 or older at enrollment attained a high school diploma or
GED.
- 13% of mothers who entered the program without a high school diploma or
GED were still working on completing their education at the time of program
graduation.
Income:
- 65% of newly enrolled
families reported an
annual household
income less than
$15,000.
$30,001-$40,000, >$40,000, 1.76%
3.44%
$20,001-
$30,000,
16.27%
$15,001-$20,000,
13.91%
$12,001-
$15,000,
11.95%
$9,001-
$12,000,
14.31%
$6,001-
$9,000,
9.18%
$3,001-$6,000,
7.43%